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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT i 1601 E. HAZE T ON AVE., STOCKTON, CA + Telephone (209) 466-6781 PERMIT EXPIRES I'YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin" w Local Health District. Job Address 4754 E. Woodbridge Rd. city Acampo Lot Size PM Owner's Name P-Au-1 5au"miDach Address 4754 _E_. Woodbri,dlrP_...Rd. Phone Contractor Goehring Pump Address 5 cense No. 309031 Phone TYPE OF WELL/PUMP: NEWWELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP._INSTALLATION ❑ -. SYSTEM REPAIR ❑ OTHE1OUEK DISTANCE TO NEAREST: SEPTIC TANK; SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WEiL PROBLEM AREA CONSTRUCTION SPECfFICAT10NS ❑ Industrial ❑ Open Bottom CI Manteca Dia. of Well Excavation Dia. of Well Casing C1 Domestic/Private --p Gravel-Pack El-Tracy--=--_- -Type-of-Casing--"-—-- -__-Specifications l F] Public 4 f' ll Delta Depth of Grout Seal Type of Grout _ I Irrigation --Approx. Depth ~I I Eastern Surface Seal-installed- ->... by . , e Repair Work Done Ll Type of Pump H.P. _ 1 State Work Done �� p" Well Destruction ❑ Well Diameter Sealing Material (top 50'1 Yaf t 1 + Depth Filler Material (Belbw 50;) TYPE OF SEPTIC WORK: NEW INSTALLATION i 1 REPAIR/-9DbiT1O'N-1 li DE=STRUCTION l 1 (No septic system permitted it public sewer is 1 .J- available within 200 feet./ �I Installation will serve: Residence_ Commercial_ Other — �'- Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. E-1Methodof Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size , FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth Size Number SUMPS LZ Distance to nearest: Well Foundation Property Line �.� DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and J rules and regulations of the San Joaquin Local Health District. Home owner or licensed ant's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in manner as to become subject to workman's compensation laws of California." Contractors hiring or sub-contracting signature cartifies the#ollowi certify that in the performance of the work for which this permit is issued, l shall employ persons subject to workman's compensa tion laws of Ca" r The applican 1 11 required inspections. Complete drawing on reverse side. Signed Title: Hkpr.• _... Date: 09/15/87 a FOR DEPARTMENT USE ONLY Application Accepted by 7 Date Area Pit or Grout Inspection by Date Final Inspection byfflDate Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 r i FEE INFO Q�AMOUNT DUE AMO 7 REMITTED CASH RECEIVED BY DATE PERMIT'NO. + EH13-24 1REV.I/y 5) T�� f ��/ — 01-IN 14-28